Electronic Health Records: Challenges

In just a decade, medical documentation has transitioned from mostly paper records to mostly electronic records. According to the Department of Health and Human Services, 78% of office-based physicians and 59% of hospitals use a basic electronic medical record (EMR) or electronic health record system (EHR).

The Beginning

This move came about largely due to a strong governmental push that began in 2004 with the establishment of the Office of the National Coordinator for Health Information Technology (ONC) by then-President Bush. The office was tasked with the goal of supporting the expansion of EHRs and helping to create a nationwide network. Not long after, in February 2009, the American Recovery and Reinvestment Act was passed under President Obama, pushing $19 billion toward the development of health information technology through the HITECH Act. This was further bolstered the following year with the passage of the ACA, which infused even more money into the system, established Meaningful Use measures and began innovative pilot programs to study ways in which high functioning EMR systems could help to improve quality of care and reduce healthcare costs.

Challenges, Galore

These rapid regulatory changes have presented major challenges to office practices and hospitals as they try to adapt to the new requirements while also remaining operationally and financially sound. Despite the huge investments that have been made in new technology, there are conflicting opinions about the value of EHRs and whether or not they will truly help improve quality of care while decreasing costs. A recent study by Medical Economics indicated that 67% of physicians are displeased with their EHR systems. Complaints about EHRs abound, but the most common include the following: high cost, weak functionality and interoperability, safety and liability risks, and interference with physician-patient and physician-to-physician relationships.

1. High Cost

Investing in EHRs can seem ironic when one of our major concerns in healthcare is skyrocketing costs. System-wide implementation of best-of-breed EHR systems, such as Epic, can run in the hundreds of millions of dollars. Beyond the up-front investment, budgets can also be blown by unexpected vendors’ fees, upgrades or ongoing maintenance needs. Unfortunately, it’s not uncommon these days to hear of hospitals going bankrupt as a result of underestimating their technology spending. Organizations must consider not only the hardware and software, but also the costs of implementation, training, support, and the potential loss of productivity during the startup phase. There’s also the concern that as consolidation occurs (with larger vendors buying up smaller ones), organizations may need to purchase entirely new EHR systems as their present systems become obsolete.

2. Functionality & Interoperability

Incredibly, there are over 1,000 electronic medical record platforms out on the market today. There are the big players with recognizable names – Cerner, Epic, Allscripts, NextGen, athenaClinicals – but there are also countless smaller vendors, some of which provide customized EMR systems for specialists. Functionality varies greatly with each system: data entry can be inefficient and time-consuming for certain systems, but not others. Other functionality issues can include slow processing, formats that are not user-friendly, or limited capabilities. Most of these systems are also highly proprietary and may not communicate well with each other. This lack of interoperability presents a barrier to the transparent communication of health information, preventing adequate coordination of care on the small scale and obstructing population health management on a larger scale. The ONC is currently working on an interoperability standards advisory that will hopefully better guide organizations as they try to develop networks with disparate EMR systems.

3. Safety & Liability

As the saying goes: “garbage in, garbage out.” An EHR system is only as good as the information that is put into it. If documentation is poor, unreliable, or unable to be accessed when needed, it poses a threat to quality of care. Additionally, there may be information in the record that should be reviewed but isn’t brought to a provider’s attention, which poses yet another kind of safety risk. We saw this happen at Texas Presbyterian Hospital in Dallas during the Ebola outbreak. Technology can also be at risk for programming errors, glitches, and power failures, paralyzing normal day-to-day functions. And, as we have heard many times in recent days, technology is at risk for data breaches, posing a threat to patient privacy and confidentiality by exposing personal health and financial information. In all of these cases, organizations can become susceptible to significant malpractice and/or liability risks.

4. Professional Relationships

Physicians like Dr. Adrian Gropper, CTO of the non-profit Patient Privacy Rights, are concerned that current systems are interfering with physician-patient and physician-to-physician relationship. Providers often complain that EMRs interfere with clinical care, making interactions more impersonal and less face-to-face, while also degrading clinical documentation. And disparate systems with poor interoperability make it difficult to communicate with other providers as well. Additionally, as organizations adopt legacy systems, referral patterns change, favoring those providers that are network-enabled and putting other, independent providers at risk of being marginalized. There’s also the growing pressure for physicians to meet state and federal health IT mandates. In an environment where there is already a shortage of primary care physicians, there is concern that EMRs will heighten physician dissatisfaction and drive a further shortage of physicians.

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These challenges are formidable, but can they be overcome? Read part 2 of this series tomorrow to learn how EHR systems can create opportunities for improving healthcare delivery.